The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement.

OBJECTIVES: This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement. STUDY DESIGN: This was a modified Delphi process. METHODS: We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised. RESULTS: We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary. CONCLUSIONS: We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Cost-effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: An economic evaluation alongside a pragmatic cluster randomised trial.

BACKGROUND: Elimination targets for hepatitis C have been set across the world. In the UK almost 90% of infections are in people who inject drugs. Evidence shows community case-finding is effective at identifying and treating undiagnosed patients. The aim of this analysis was to assess, from a healthcare provider perspective, the cost-effectiveness of a new pharmacist-led test and treat pathway for hepatitis C in opioid agonist treatment (OAT) patients attending community pharmacies compared to conventional care. METHODS: In a cluster randomised controlled trial, pharmacies were randomised to the pharmacist-led or conventional care pathway. Mean cost per OAT patient and per patient initiating treatment was identified for each pathway. A Markov model tracking disease progression was developed, with a 50-year time horizon and 3·5% time discount rate, to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained and the probability of being cost-effective at a £30,000 per QALY willingness-to-pay threshold. Probabilistic sensitivity analysis was performed for a range of drug discounts, re-infection rates, and model assumptions. FINDINGS: Mean cost per OAT patient (£3,674 vs £1,965) and per patient initiating treatment (£863 vs £404) was higher in the pharmacist-led pathway, due to higher uptake of testing and pharmacist time requirements. Over a 50-year time horizon the ICER per QALY gained was £31,612 at NHS indicative price for treatment (£38,979 for 12 weeks) and 12·1/100 person-years re-infection rate, reducing to £21,027/£10,220/-£501 per QALY gained with 30%/60%/90% drug price discounts and £25,373/£21,738/£14,912 per QALY gained at re-infection rates of 8/5/2 per 100 person-years. At 30%/60%/90% drug discount rates, the pharmacist-led pathway has an 80%/98%/100% probability of being cost-effective. INTERPRETATION: The pharmacist-led pathway is effective at increasing testing and treatment uptake, with cost-effectiveness being highly dependent on drug price discounts. FUNDING: Trial funding provided by the Scottish Government, Gilead Sciences, and Bristol-Myers Squibb.

Evaluation of anticoagulant control in a pharmacist operated anticoagulant clinic.

AIMS: To compare the quality of outpatient anticoagulant control before and after the transfer of dosing responsibility to designated trained pharmacists from rotating junior medical staff. METHODS: All International Normalised Ratio (INR) values for an eight month period either side of the staff changeover were assessed for precision of therapeutic control according to described standards. Allowing for patient associated effects, observed and expected frequencies of "successful" control for the two staff groups were compared under the hypothesis of no association. RESULTS: INR results (n = 2219) for 382 patients were analysed. For patients in stable therapeutic control, there was no significant difference in performance between the two staff groups. Patients with an INR result "out" of control limits were more likely to be returned "in" to control at their next visit by the pharmacists than by the doctors. CONCLUSIONS: The quality of anticoagulant control in outpatient clinics benefits from dedicated trained staff using standard protocols.

Bearing illness: study of couples where the husband awaits coronary graft surgery.

This paper reports findings from the first of a series of interviews with men treated by coronary grafting, and with their wives. Seen immediately after angiography, these couples were asked about their social and conjugal roles, attitudes to the men's illness, and changes to their circumstances. Clustering the couples on these responses yielded four groups: strained relationships in which husbands who had given up work had become withdrawn but were supported by wives who had increased the burden of their responsibilities; strained relationships in which husbands forced to give up outside engagements took on household duties from wives who were less concerned about their spouses' activity levels; where husbands who had modified their activities, and wives who showed most concern, together made mutual adjustments in relation to the illness; where husbands had experienced little need for change and, together with their wives, had largely maintained a 'normal' life. A measure of adjustment to illness showed that there were parallels between the relationship of patient to illness, and of husband to wife in each group. A theoretical proposal is offered integrating these two forms of relationship, and inferences are drawn regarding the counselling of patients and wives in the period prior to graft surgery.

The embodiment of social relations in coronary heart disease.

Recent work on the behaviour pattern characteristic of men developing coronary heart disease (CHD) has been aimed at increasing the predictive utility of methods designed to assess 'proneness' and at refining the Type A typology. This has had the indirect effect of restricting the elaboration of theory relating to clinical evidence drawing upon the personal and social context of CHD. This paper reviews such evidence and concludes that explanations of 'coronary-prone behaviour' should acknowledge that it is embedded in particular uses of the body and in particular forms of social relationship. Based upon this premise, a conceptual analysis is presented to demonstrate that 'coronary proneness' is insufficiently described as a behaviour pattern, but is more usefully considered as a mode of action constituting a contradiction in the person's social relationships. It is further proposed that the bodily style of many CHD patients is necessarily understood as an expression of the development of this modality.

Health psychology and the study of the case: from method to analytic concern.

This paper recommends that the study of the case be seen as of primary analytic concern to social scientists, and particularly to health psychologists. Criticism is made of the idea that a case is merely a medical instance or a methodological option. Instead, we argue that health psychologists should re-direct their attention to the 'study of the case' as being central to issues concerning health, illness and healing. There are three reasons for doing this. First, case study is basic to any procedure that involves collecting information about the context in which medicine is practiced. Second, communication between health professionals involves presenting the clinical situation of their patients as storied accounts, so that cases are made, not found. Third, there is presentational work by patients, involving communications of (as well as about) suffering and relief. This last feature is basic to how doctors and health psychologists, especially those engaged in clinical work, understand individuals as 'cases'. The paper explores differences between these different forms of case, while emphasizing portrayal as a key feature of all of them. In justifying the study of the case on conceptual as well as on clinical and methodological grounds, we highlight the position of health psychology in its attempts both to study and to intervene in health-care contexts.

Styles of adjustment to coronary graft surgery.

Using Herzlich's descriptions of styles of adaptation to illness a conceptual scheme is offered which sets out four potential modes of adjustment to illness (ACCOMMODATION, ACTIVE-DENIAL, RESIGNATION, SECONDARY GAIN). A study is reported in which a group of 40 patients attending for CABGS were interviewed to assess their adjustment style, their expectations of surgery and their pattern of activities. A second group of 40 patients who had received CABGS approx. 11 months previously were also interviewed regarding their course of recovery, activity pattern and style of adjustment to illness. Results indicate that the same adjustment styles may not be employed prior to surgery as are adopted during recovery. Specific findings indicate that different styles of adjustment are consistent with different expectations of surgery; with changes in patterns of activity; and with particular courses of recovery. These differences were not explicable in terms of the degree of angina reported by patients either prior to or following CABGS. Discussion of these and related findings point to the explanatory potential of the conceptual system outlined in the paper, within which scheme further questions of adjustment to illness can be addressed.

Health psychology, embodiment and the question of vulnerability.

The topic of the body is now firmly on the agenda for psychology, as it has been for sociology for some time. What contribution will health psychology make to this debate? This article argues that the biomedical view of the physical body is inappropriate for a psychology addressing the key concerns of suffering and healing. Instead, health psychology needs to theorize what it means to be embodied in the context of illness and of health care. To do this requires investigation of the practical relationships between staff and patients as well as of experiences of sufferers. By reflecting critically upon the relationship between clinical practice and the conceptualization of the body, a health psychology embracing the idea of embodiment becomes possible.

An evaluation of the potential interaction between enalapril and amiloride.

Enalapril was shown to have no effect on the serum potassium of patients (n = 16) already taking Frusemide and Amiloride. Furthermore, there was no difference in serum potassium levels of the group taking a combination of Enalapril, Frusemide and Amiloride when compared to a similar group of patients taking Frusemide and Amiloride alone (n = 19). No patients in either group were deemed to have seriously impaired renal function. The results indicate that the theoretical hyperkalaemic effect of concurrent administration of Enalapril and Amiloride is not manifest in clinical practice in patients with normal renal function.

Impending surgery: the expectations of male coronary patients and their wives.

Waiting to receive coronary graft surgery presents patients and their spouses with a stressful episode which nevertheless holds out the possibilities of symptom relief and improved quality of life. This study examines differences between couples in their experience of waiting, approach to surgery and expectations of treatment benefit. These differences, conceptualized in terms of a theory of adjustment to illness, are discussed in relation to their practical implications for helping patients and spouses to prepare for surgery and its possible outcomes.

Development of patient-centred performance indicators to guide the delivery of pharmaceutical care in a district general hospital.

The aim of this study was to audit clinical pharmacy practice in an acute hospital setting against the individual patient care guidelines set out in the CRAG "Framework for Practice" document, and then to develop practical, patient-centred performance indicators that could be used locally to monitor the delivery of pharmaceutical care. A series of four audits were undertaken to establish key elements in the process of providing pharmaceutical care to patients. Four standard statements describing the performance of the pharmacy service in providing patient care were developed through peer discussion and formulation of ideas based around these data. The four standard statements were then used as performance indicators to evaluate service performance at PRI and tested by means of a further audit cycle. The use of this methodology facilitated operation of a structured service appraisal system and provided a forum that allowed problems with practice to be discussed and resolved.

Reversing the process of thought disorder: a serial validation experiment.

Previous personal construct theory studies of thought disorder suggest that it can be viewed as a state of grossly loosened construing (a weak and unstable network of links between ideas) and that it can fairly be measured by grid method. Later studies in the series indicated that it is people not things which bewilder the thought-disordered patient--it is his role as a 'psychologist' that is specifically damaged. The serial invalidation hypothesis argued that thought disorder is the long-term consequence of a repeated failure to predict accurately the behaviour of others and self, resulting in the disintegration of any organized, personal 'theory' about relationships. The present experiment attempt to reverse the process of thought disorder by first identifying whatever weak, remaining system of expectations the thought-disordered patient manifests and then fulfilling these expectations. Such a process of serial validation might lead to a strengthening of the 'theory' which generated these expectations--a tightening of the construct system. Experimental and control group were closely studied over a two-year period. Results-while tending in the predicted direction--yield a not proven verdict though they leave the argument viable and the experiment worth modified replication.